2017 Home Health Survey Part A : General Information 1. Identification UID:HHA053 Facility Name: Encompass Home Health of Georgia County: Muscogee Street Address: 6001 River Road, Suite 220 City: Columbus Zip: 31904 Mailing Address: 6688 N Central Expressway, Suite 1300 Mailing City: Dallas Mailing Zip: 75206 Medicaid Provider? Check the box to the right if the agency is a medicaid provider If you indicated yes above, please report the medicaid number below. 000696407A Medicare Provider? Check the box to the right if the agency is a medicare provider If you indicated yes above, please report the medicare number below. 11-7306 2. Report Period Report Data for the full twelve month period, January 1,2017 - December 31, 2017 (365 days). Do not use a different report period. Check the box to the right if your facility was not operational for the entire year. If your facility was not operational for the entire year, provide the dates the facility was operational. Part B : Survey Contact Information Person authorized to respond to inquiries about the responses to this survey. Contact Name: Tracey Kruse Contact Title: Chief Operating Officer Page 1 Phone: 214-239-6500 Fax: 214-239-6581 E-mail:
[email protected] Part C : Ownership, Operation and Management 1. Ownership, Operation and Management As of the last day of the report period, indicate the operation/management status of the facility and provide the effective date. Using the drop-down menus, select the organization type. If the category is not applicable, the form requires you only to enter Not Applicable in the legal name field.